Follow-up·September 21, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct a case management of facility and met with Business Office Director Liz Alfaro regarding uncleared citation pertaining to First Aid certifications. LPA is conducting this case management visit in order to clear deficiency previously cited during Post Licensing visit that occurred on 8/22/2023. POC due date was 8/31/2023 but on due date Administrator Savoie requested extension to 9/20/2023 which LPA granted. During today’s visit LPA was provided proof of First Aid certifications for staff (S1, S2, & S3) that was completed on 9/19/2023. LPA cleared citation at visit & provided Business Office Director (BOD) documentation. During Post Licensing inspection on 8/22/2023 LPA observed Garden Neighborhood dining area blocked off (inaccessible to residents in care) due to water leak under the dishwasher causing damage to the floors and wall. Facility in process of making repairs. During today’s (9/21/2023) visit LPA observed same area still under repair, with progress made. LPA was informed by Building Services Director Russell Echevira, anticipated completion of repairs, including replacement of new kitchenette to be approximately 30 days. LPA was presented with receipts, work order documentation, and schedule. While at facility conducting case management LPA was informed by BOD of incident report submitted to CCL last night of a medication error that occurred from 9/3/2023 to 9/10/2023 where Resident (R1) had been given pain reliever for 3 days, then was to be as needed, although facility continued with original order surpassing 3 days for 8 additional days of scheduled medication. PCP notified of incident, R1 back at baseline without any adverse side effects. Facility is being cited today for medication error. (see LIC809-D). Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.